The investigative interviewing of eyewitnesses is an important part of the judicial system and is essential in police investigations to identify culpable parties. However, interviewing witnesses to elicit accurate recall is not without some flaws (Ainsworth, 2002). Researchers have acknowledged that recall of information is a complex process vulnerable to variables which impede the retrieval of accurate information (Gudjonsson, 1996; Loftus, 1979; 1992). To improve witness recall, psychologists developed the Cognitive Interview (CI) procedure to help interviewers retrieve more correct information from witnesses (Fisher & Geiselman, 1992). The use of the CI has been shown to increase accuracy in many populations (Memon, Holley, Wark, Bull, & Koehnken, 1996; Milne & Shaw, 1999). However, there are some criticisms of the CI. For example, the CI may cause confusion for witnesses (Kebbell, Milne, & Wagstaff, 1999), takes longer to administer than a standard police interview (Croft, 1995) and contain components which are reported to undermine the effectiveness of this procedure (Boon & Noon, 1994). This research program utilised three studies in a multimethod approach to evaluate investigative interviewing procedures, from an experimental and applied perspective. The overarching aim of this research was to identify a parsimonious, effective and efficient interview procedure which overcame some of the limitations recognized in the CI. The first study employed an experimental methodology to test the effectiveness of the CI and two alternative versions of the CI, to determine which interview procedure resulted in the most correct and least incorrect amounts of information being elicited from student witnesses to a road incident stimulus. Results indicated that the truncated group utilizing mnemonics Tell All and Reinstate Context elicited as much correct and less incorrect information than the ‘Full CI’ group, and took less time to administer. Study Two examined the perceptions of the interview procedure from the witnesses’ perspective. Witnesses were asked to complete a questionnaire which was designed to investigate what the participants thought about how the interview was conducted. Results indicated that, overall, the witnesses found that the interviewers engaged in practices and behaviours at a similar skill level and appreciated the rapport building and clarity of the interviewers. A content analysis revealed that the witnesses favoured some mnemonics over others. The qualitative statements made in regard to questions in the questionnaire are presented. Study Three used a triangulation methodology to determine what the Queensland Police Service officers were currently trained in and practising in the field. Secondary sources, a questionnaire, focus group and case study methodologies were used to make this determination. Findings indicated that there were areas where the police service could improve training of officers to help facilitate interviewing of witnesses. The integration of the findings from the three studies will help to inform the current state of research in the area of investigative interviewing. In particular, this research provides a target examination of interviewing practices in a sub-section of the Queensland Police Service. The findings from the three studies were used to identify an interview procedure which obtained more correct information, did not gain an increase in incorrect information, reduced the time required to conduct the interview, was not confusing for the witnesses, or the officers, and contained no inherent problems for the judicial system. Further recommendations are made for the use of interview protocols for investigative interviewing of road incidents.

Thesis (Ed. D.)--State University of New York at Binghamton, School of Education, 2007. / Includes bibliographical references.

Dissertation (Ph.D.)--University of South Florida, 2009. / Title from PDF of title page. Document formatted into pages; contains 295 pages. Includes vita. Includes bibliographical references.

Thesis--Munich. / Issued also, without thesis statement, in 1973 under title: Präsidenten-Krieg in Vietnam? Includes bibliographical references (p. 336-350).

<p>I den svenska vården drabbas uppskattningsvis var tionde patient av en vårdskada, det vill säga en undvikbar skada direkt orsakad av vården (Socialstyrelsen, 2008; Ödegård, 2007). Vårdskador ska registreras som avvikelser som sedan ska analyseras för att finna orsak och ligga till grund för förbättringsarbete (Socialstyrelsen, 2008). Syftet med studien är att beskriva innehållet i de patientavvikelser som registrerats av personal på sjukhus. Innehållet beskrivs avseende vilka händelser som registrerats och vårdpersonalens beskrivningar av händelseförloppet. Studien innehåller både kvalitativa och kvantitativa delar. Den kvalitativa delen genomfördes med innehållsanalys enligt Graneheim och Lundman (2004). Den kvantitativa delen redovisas med hjälp av deskriptiv statistik. Resultatet av studien visar att de flesta avvikelser berör Organisation/regler/resurser, Vård och behandling samt Halk/fall. Patienter i åldern 70-90 år drabbas i störst utsträckning. Händelseförloppet är ofta detaljerat beskrivet. Personal är däremot mindre benägen att skriva vad de anser vara orsak till det inträffade, samt bidra med förbättringsförslag. Teman som kom ur den kvalitativa analysen var: ”Det blir arbetsamt när andra gör fel”, ”Att vara nära men inte inpå” och ”Att lindra lidande”.</p>

Submitted by Aelson Maciera (aelsoncm@terra.com.br) on 2017-08-30T18:21:41Z No. of bitstreams: 1 DissLAR.pdf: 6944242 bytes, checksum: ce12353d984d6052b57da16f8fb7cc77 (MD5) / Approved for entry into archive by Ronildo Prado (ronisp@ufscar.br) on 2017-09-06T19:14:02Z (GMT) No. of bitstreams: 1 DissLAR.pdf: 6944242 bytes, checksum: ce12353d984d6052b57da16f8fb7cc77 (MD5) / Approved for entry into archive by Ronildo Prado (ronisp@ufscar.br) on 2017-09-06T19:14:09Z (GMT) No. of bitstreams: 1 DissLAR.pdf: 6944242 bytes, checksum: ce12353d984d6052b57da16f8fb7cc77 (MD5) / Made available in DSpace on 2017-09-06T19:17:34Z (GMT). No. of bitstreams: 1 DissLAR.pdf: 6944242 bytes, checksum: ce12353d984d6052b57da16f8fb7cc77 (MD5) Previous issue date: 2017-02-20 / Não recebi financiamento / The process in healthcare may not produce desirable outcomes and strategies of risk minimization should be adopted to improve patient and professional safety. A risk management tool commonly used in high reliability industries (eg, aviation, nuclear power plants and petrochemicals) is incident learning, consisting of a systematic process of investigating deviations in the normal behavior of a system to extract information to improve their performance. This dissertation aims to develop an Incident Learning System (ILS), to implement it at a radiotherapy service in a cancer hospital and to analyze the critical success factors to use this tool. A literature review and an action research were carried out to implement the ILS, focusing on the perspective of the professionals involved. The records were analyzed by a multidisciplinary committee of professionals of the radiotherapy service (action research group) through a formal and structured process for investigation and classification (categorization) of the incidents. Based on the incidents analysis, the patient care process and the professionals working conditions were constantly evaluated critically and actions taken to reduce risk were proposed as a way to promote organizational learning. This was done by analyzing each incident individually and also by statistical analysis of the classification data, allowing identify patterns of performance common to the set of incidents. The greatest number of occurrences and detections of incidents occurred in the "Treatment" stage of the radiotherapy process. Major safety barriers, active and latent failures have been identified and improvement actions have been established for these most vulnerable areas. The ILS implementation process was constantly evaluated through participant observation, interviews and questionnaires, in order to improve the learning mechanisms. As a result of these evaluations and the review of the main implementation challenges observed in other publications in the area, a list of guidance issues was proposed to assist in the establishment of an ILS in the routine of a radiotherapy service. / O processo de cuidado ao paciente na área da saúde pode não produzir resultados desejáveis e estratégias para minimização de riscos devem ser adotadas a fim de melhorar a segurança do paciente e dos profissionais. Uma ferramenta de gerenciamento de riscos comumente utilizada em indústrias que requerem alta confiabilidade (por exemplo, aviação, usinas nucleares e petroquímica) é a aprendizagem com incidentes, que consiste em um processo sistemático de investigação de desvios no comportamento normal de um sistema com o objetivo de extrair informações para a melhoria de seu desempenho. O objetivo desta dissertação é desenvolver um Sistema de Aprendizagem com Incidentes (SAI), implementá-lo em um serviço de radioterapia de um hospital oncológico e analisar os fatores críticos de sucesso para utilização desta ferramenta. Foi realizada revisão bibliográfica e uma pesquisa-ação para implementação do SAI com foco na perspectiva dos profissionais envolvidos. Os registros efetuados foram analisados por um comitê multidisciplinar de profissionais do serviço de radioterapia (grupo de pesquisa-ação) por meio de um processo formal e estruturado para investigação e classificação (categorização) dos incidentes. A partir das análise dos incidentes registrados, o processo de tratamento dos pacientes e as condições de trabalho dos profissionais foram constantemente avaliados criticamente e ações de melhoria e redução de risco foram propostas como forma de promover a aprendizagem organizacional. Isso foi feito a partir de análises de cada incidente e também por meio da análise estatística dos dados de classificação, permitindo identificar padrões de desempenho comum ao conjunto de incidentes. O maior número de ocorrências e detecção de incidentes se deu na etapa “Tratamento” do processo da radioterapia. As principais falhas de barreiras de segurança, falhas ativas e latentes foram identificadas e ações de melhorias foram estabelecidas para estas áreas mais vulneráveis. O processo de implementação do SAI foi constantemente avaliado por meio de observação participativa, entrevistas e aplicação de questionários, a fim de melhorar os mecanismos de aprendizagem no serviço. Como resultado destas avaliações e do levantamento das principais dificuldades de implementação, observadas em outras publicações sobre o tema, foi proposta uma lista de questões de orientação para auxiliar no estabelecimento de um SAI na rotina de um serviço de radioterapia.

Introduction: In recent decades, there has been considerable international attention directed towards minimising healthcare-associated harm and improving the safety of hospital care. More recently, this attention has broadened to include primary medical care. In 2002, the World Health Assembly recognised the issue of inadequate levels of patient safety as a major threat to global public health. In the following years, many countries have developed national strategies for the measurement, monitoring and prevention of patient safety incidents (PSIs) and their outcomes. Experience accumulated from secondary care has shown that the initial steps for understanding patient safety include the systematic identification of the most frequent and most harmful threats. However, the safety profile of primary care dentistry remains poorly investigated. As a result, current evidence cannot provide reliable estimates of the types of PSIs in primary care dentistry, the causes of these incidents, or the associated disease burden caused by such incidents. In medicine, improvements in patient safety were achieved at a national level by developing a shared conceptual understanding, the standardisation of terminology and through preventive initiatives such as the introduction of a national incident reporting and learning system. In the United Kingdom (UK), the England and Wales’ National Reporting Learning System (NRLS) has been an important source of insight, from the perspectives of the reporter, into understanding why PSIs occur. This initiative has led to the implementation of patient safety oriented policies to monitor and reduce cases of healthcare-associated harm. Examples of such policy initiatives include national guidelines and national safety recommendations to encourage the reporting of serious reportable events called ‘never events’ (NEs). These are defined as serious, preventable PSIs that should not occur if the available preventive measures are implemented. At a national level, serious incidents and NEs must be reported to the NRLS and/or other reporting systems. However, little is known about NEs in dentistry as wrong-tooth extractions are the only currently defined NE that has a clear application in dentistry. Although surgical NEs, such as wrong-site surgery and wrong implants may be related to dental procedures, these overlap with procedures conducted in secondary care. As a result, there is no agreed list of NEs for primary care dentistry. The overall aim of my PhD was to explore patient safety, its concepts, including error and harm, and how these can help to create an understanding of the types of PSIs that occur in primary care dentistry, their contributory factors and their consequences. In addition, I also aimed to identify NEs with the greatest need and opportunity for future intervention strategies, in order to improve patient safety in primary care dentistry. Methodology and methods: My PhD was conducted in three phases. For the first phase, I conducted a systematic scoping review of the empirical evidence published over a 20-year period (1994-2014). To achieve this, I searched MEDLINE and EMBASE for articles reporting incidents that could have or did result in unnecessary harm from primary dental care. I also extracted and synthesised data on the types and frequencies of PSIs (including NEs) and adverse outcomes. Then, for the second phase, I undertook an exploratory sequential mixed-methods evaluation, which involved the qualitative exploration and analysis of a weighted-by-year randomised sample (n=2,000) of the most severe incident reports from primary care dentistry submitted to the England and Wales’ NRLS. This approach generated three coding frameworks, aligned to the International Classification for Patient Safety developed by the World Health Organization, for i) the classification of incidents, ii) contributor y factors and iii) incident outcomes. These coding frameworks informed the quantitative analysis, during which myself together with a trained second coder, applied codes to deconstruct the narrative of these patient safety incident reports whilst retaining the meaning of the report. To assess inter-rater reliability, Cohen’s Kappa statistic was calculated for the primary incident type which was defined as “the incident that resulted in the outcome experienced by the patient.” Finally, for the third phase, I undertook an electronic Delphi exercise to achieve international agreement on NEs for primary care dentistry. The results obtained from Phases 1 and 2 were used to identify candidate NEs. I then invited an international panel of 41 experts to complete two rounds of questionnaires; 32 (78%) agreed to participate and completed the first round, and 29 (91%) completed the second round. I provided anonymised controlled feedback between rounds and used a cut-off of 80% agreement to define consensus. The results from the first stage built the evidence base for the second and third phases. Likewise, the results from the second phase further informed the third and final stage of my PhD. Results: I undertook a systematic scoping review which demonstrated: a) there were considerable differences in definitions for terms used to describe patient safety, b) that a range of populations had been studied, and c) that major differences in sampling strategies exist between studies. The main five PSIs I identified were errors in i) diagnosis/examination, ii) treatment planning, iii) communication, iv) procedural errors and v) the accidental ingestion or inhalation of foreign objects. However, little attention has been paid to wider organisational factors such as problems within the physical environment, scheduling (e.g. errors in managing appointments) and patient access, management and lines of responsibility. Also there is very little evidence of interest in researching into the influence of policies for either quality or patient safety assurance. The retrieved evidence was used to build a conceptual literature-derived model of patient safety risks in primary care dentistry. This model helped to bring structure to the analysis of the 1,456 patient incident reports that were eligible for analysis out of a total of 2,000. These reports described incidents across the preoperative (40.3%; n=587), intra-operative (56.1%; n=817) and post-operative (3.6%; n=52) clinical stages of care delivery. Further analysis showed the more frequently reported incidents were related to a) delays in treatment (333/1,456; 22.9%), b) procedural errors (220/11,456; 15.1%), c) medication-related adverse incidents (160/1,456; 11.0%), d) equipment failure (90/1,456; 6.2%) and e) errors in obtaining or processing x-rays (87/1,1456; 6.0%). Only 5.3% (77/1,456) of the incidents resulted in harmful outcomes. Of the 77 incidents that resulted in a harmful outcomes (n=77; 5.3%), around half were due to wrong tooth extractions (37/77; 48.1%) and resulted in unnecessary procedures. Three out of the 1,456 incidents (0.2%) resulted in death. Data from the scoping review and the mixed-method analysis informed a list of 42 candidate NEs. I further sought and achieved international consensus for 23 of these NEs. These were related to routine assessment, and pre-operative, intra-operative and post-operative stages of dental procedures. Conclusions: The findings from my PhD have revealed that patient safety research in dentistry is mostly descriptive and poorly organised with various approaches to defining and measuring PSIs and their outcomes. This poor organisation of patient safety research also includes differing study designs and patient populations studied. The evidence-based conceptual framework from the systematic scoping review, and coding frameworks from analysis of PSI reports selected from a national database, can bring structure to future work by providing a robust approach to classifying PSIs, their contributory factors and outcomes. / My research findings also show that PSI reports are an important source of information that can generate important insights about patient safety in primary care dentistry. The mixed-method analysis of PSI reports showed that most incidents in primary dental care do not result in harm. PSIs that resulted in harmful outcomes more frequently occurred intra-operatively. My findings also reveal that unsafe care in dentistry is not limited to human error, but can also be ascribed to the presence of other administrative or organisational flaws that contribute to the reported incidents. Future initiatives to improve and research clinical practice should focus on improving administrative processes to reduce delays in treatment. Also, the reduction of procedural errors through the standardisation of x-rays, medication prescription and other clinical procedures is needed. Lastly, I have constructed the first comprehensive international list of NEs for primary care dentistry. I believe my findings, including the list of NEs, can provide an evidence-base which will encourage researchers to further expand the patient safety research and development agenda in dentistry, as well as encouraging decision-makers and professional bodies to translate my findings into quality improvement strategies.

Este estudo tem por finalidade modelar a pegada ecológica de incidentes rodoviários que interrompem o fluxo normal de circulação. A pegada ecológica é um indicador que mede o impacto das atividades humanas em quantidades de áreas de terra, água e energia utilizadas para sustentar uma população de determinada região. Em transportes, esse impacto é medido pela área hipotética que deveria ser reservada para a absorção do CO2 emitido que tem constituído, nos últimos anos, a fatia mais significativa das pegadas ecológicas na maioria dos países. A vantagem de utilizar essa abordagem reside na facilidade de entendimento, na simplicidade e na utilização de uma unidade única de comparação entre emissões de diferentes setores. O método proposto e aplicado neste trabalho proporciona a identificação dos impactos dos incidentes, particularmente acidentes viários e obras de manutenção viária, em termos de pegada ecológica. O estudo de caso constou de uma rodovia de pista simples cujas emissões foram avaliadas com a utilização de simulação de tráfego. Como resultado obteve-se uma pegada ecológica de cerca de 2.180 hectares decorrente dos incidentes ao longo de um ano de operação da via. Este valor corresponde a 4% da pegada ecológica da via em condições normais de operação. Ainda, os resultados indicam que os incidentes com maior impacto sobre o meio ambiente são as obras para a manutenção da rodovia que contribuem com 60% do total gerado pelos incidentes. / The purpose of this study is to model the ecological footprint of road incidents that interrupt the normal flow of vehicles. The ecological footprint is an accounting framework that measures the impact of human activities considering amounts of land, water and energy areas used to sustain the population of a region. In transportation, this impact is measured by the hypothetical area required to absorb CO2 emissions from burning fossil fuels that has been responsible, over the last years, for the largest share of the ecological footprint of nations. The advantage of using this approach is the ease of understanding, simplicity and the use of a single unit for comparing emissions from different sectors. The method proposed and deployed in this work enables identifying the impact of incidents, basically road accidents and maintenance works, on the transportation ecological footprint. The case study was composed of a single lane highway whose emissions were evaluated with the use of traffic simulation. We obtained an ecological footprint of 2,180 ha due to road incidents over a period of one year. This corresponds to 4% of the ecological footprint of normal road operations. Results also indicate that the incidents with the greatest impact on the environment are the works for the maintenance of the highway which contribute with 60% of the total value.

The Czech Environmental Inspectorate (CEI, Inspectorate), a body established by the Ministry of the Environment and led by a director, is divided into directorates, ten regional inspectorates and two branches. The objective of this thesis is to provide an overview of the activity carried out by the CEI according to Act No. 59/2006 Coll., about Prevention of Serious Incidents, as amended (hereafter Act). The CEI has been conducting this activity in cooperation with district offices and integrated inspectorates. Among the main activities of the CEI, according to the aforementioned Act, belong processing and discussing the proposal of a year?s inspection plan, organising inspections, creating the final inspection report, inspecting compliance with provisions of the Act by the operator and in case of identifying failures in fulfilling these obligations, prescribing corrective measures or a penalty. The selected methodology assessed the current status through available materials, in particular valid legislation, annual reports, internal regulations of the CEI and Ministry of the Environment. The practical part is based on the theoretic findings and a survey among the CEI experts engaged in this area. The survey was divided into two individual parts. The first part focuses on finding out expert opinions. The other part is made of a test of experts? knowledge. The area of valid legislation focused on its complexity, division of competencies between integrated inspectorates, the frequency of inspections and levels of penalties. Based on the available results there is satisfaction with complexity of legislation; however, it was pointed out that there is occasional duplicity of competencies of individual integrated inspectorates. The frequency of inspections and the levels of penalties stipulated by law were viewed very positively. Another examined area was cooperation with other integrated inspectorates and district offices during joined-up inspections. The area was assessed by all approached CEI experts as absolutely without any issues. Another assessed item was cooperation with the appeal body, i.e. Ministry of the Environment. In this area there is discontentment for the reason of the appeal body cancelling or reducing penalties. Cancelling penalties occurs for the reason of process errors when conduction inspections or disunity in interpreting the valid legislation. The area of personnel support was assessed as sufficient with a note that with respect to the drop in the number of employees as part of cost efficiencies, there would be a lack of employees. In case of inspectors working under the Department of Water Protection, there were two solutions defined: either leaving the existing status or including this area under the Department of Waste Management where integrated prevention also sits at the moment. The last reviewed area is training of new inspectors and developing the current ones. The area of training new inspectors was assessed as insufficient, in particular its practical part. Therefore, the only possible solution is to amend the methodical instruction to train new employees and include more practical preparation. Another point was developing the current insp ectors. Furthermore, it was suggested to introduce regular re-examining of inspectors, approximately once in two years and always when legislation changes. The last examined area was to assess the knowledge level of experts of prevention of serious incidents. The test contained 15 questions and only ten experts participated in it. The average score of errors was one error per one expert. This result can be perceived as very good and it can be said that knowledge is on a very good level. In conclusion, it is necessary to add that the CEI operates in the examined area as a body of prevention and therefore its activity in this area plays a vital role in the fight to prevent serious incidents from occurring.

In the last decades there was an evolving theoretical and practical discussion about the implementation of corporate social responsibility (CSR), partially provoked due to the occurrence of incidents which were caused by negligently companies. Furthermore, there is a disagreement of financial outcomes of the implementation of CSR strategies in prior research. The thesis contributes to the limited established empirical research on the impact of social incidents on company’s CSR transparency and social performance of companies listed in European Union Member States. Furthermore, the thesis examines the impact of social performance on financial performance based on 308 observations in a time range of 2012 to 2014. The author finds no significant relationship between incidents and an improved CSR transparency or social performance for the overall sample at any conventional level. However, the author finds a positive significant relationship between social performance and financial performance, measured by the logarithm of Tobin’s q, which indicates that social performance has a positive impact on financial performance.